Coordinator - Utilization Management
Company: ApolloMed
Location: Monterey Park
Posted on: June 14, 2022
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Job Description:
SUMMARY
The Utilization Management Coordinator is responsible for
supporting clinical, management, and client activities that
comprising the UM Program. The Utilization Management Coordinator
must be proficient in all UM processes such as and understanding of
the CCS process, what requires precertification from health plan,
Division of Financial Responsibilities, Delegation agreements and
Health Plan contracts. The UM Coordinator will ensure we are
processing quality referrals in a timely manner meeting the health
plan standards.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Comply with all UM policies and procedures. Annual review of
selected UM policies.
Process Routine, Urgent & Retro treatment authorization requests
according to the NMM Policy & Procedure and Health Plan turn-around
time standards. NMM will use these timeframes for consistency
Pharmacy requests 24 hrs
Urgent 72 hrs- Calendar days
Routines 5 days- Business days
Maintain understanding of business rules and regulatory
requirements pertaining to UM processes and operations
Accurately review, screen and process daily assigned UM referrals
(average 200 referrals/day) in accordance with IPA and health plan
TAT guidelines
Coordinator will check that all required fields are completed
correctly. If missing DX and or CPT a call will be made to the
provider while they are screening.
Coordinators will use level 1 guidelines to release referrals that
meet specific business rules
If benefit check required document what specifics are to be
checked
If referral requires clinical review or are above a Level 1
guideline, the referral is sent to the nurse queue for review.
Urgent and or Routine nurse queues.
Contact the provider office as needed for clarification of ICD 10
or CPT codes and or to request medical records.
Maintain high level of accuracy when processing referrals. Random
audits will be done to verify.
Responsible for verification to include but not limited to: benefit
matrix through DOFR, eligibility, provider status
(contracted/non-contracted), CCS, carved out and others.
Responsible for obtaining authorization approvals from the
appropriate physician assigned to that IPA.
Monitor reports to ensure that the coordinators are meeting the
established TAT.
Work the inquiry emails to respond to UM questions from Member
services or provider relations.
If assigned to work the Medical Director queue, the coordinator
will process as per the Medical Directors
instruction.
Coordinator will release those that are approved
Coordinator will populate the required fields for the denial and or
redirection and forward to the denial team to process the
request.
Attend to provider and interdepartmental calls in accordance with
exceptional customer service
Ability to keep high level of confidence and discretion when
dealing with sensitive matters relating to
providers and members.
Report any issues to Supervisor and or Manager.
Maintains strictest confidentiality at all times.
OTHERS:
Back up to Supervisor or Manager when he or she is not
available.
Maybe required to cover occasional weekend and or holiday to
maintain our required TAT.
Attend to provider and interdepartmental calls in accordance with
exceptional customer service
Maintain good relationships with health plans and medical directors
and external contacts.
Performs other duties, projects and actions as assigned
Team-player, assist others as needed in order to comply with
TAT.
Support departmental initiatives such as policy/procedure review,
audit preparation
Other duties as assigned
QUALIFICATIONS:
REQUIRED:
High School Diploma or GED
Experience with Microsoft applications such as Word, Excel and
Powerpoint
PREFERRED:
A minimum of two years experienced in managed care environment to
include but not limited to an IPA or MSO preferred
Experience using EZCAP
#LPIND
Keywords: ApolloMed, Monterey Park , Coordinator - Utilization Management, Executive , Monterey Park, California
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